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Moral Injury Is the Result of a Broken System That Requires Repair


Burnout among clinicians has been an issue for a number of years. A report by the National Academy of Medicine states that 35% to 54% of U.S. nurses and physicians manifest significant symptoms of burnout, including exhaustion, cynicism, and decreased productivity.

According to the report, factors contributing to nurse burnout include challenging workloads and work schedules, staffing ratios, inefficient workflows, and time spent on administrative tasks.

Many clinicians, however, are disheartened by discussions of burnout. Too often, these discussions frame the problem as one of broken people rather than a broken system, with solutions that often revolve around strengthening personal resilience through self-care and better coping strategies. That may explain why the concept of moral injury has been gaining traction in the last couple of years as a way of describing the crisis at the heart of the healing professions.

Moral injury has been described as a "deep soul wound" that occurs when a person feels they must take actions, or witness actions, that violate their deeply held moral beliefs. Nurses, who entered the healthcare industry with a calling to care for others, may experience moral injury when they are unable to ensure that patients receive the care they need.

They may feel a disconnection between the values that led them into their profession and the realities that create the compromises they must make from day to day amidst financial and regulatory imperatives and inadequate care models that shift focus away from the vital patient-clinician relationship.

Moral Injury Compounded by COVID-19

The COVID-19 pandemic placed intense pressure on the nursing workforce and, in many settings, has meant that nurses are confronted daily with morally challenging dilemmas. Indeed, articles in both the New England Journal of Medicine and JAMA describe sources of moral injury associated with the pandemic, such as fears of not being able to protect oneself, one's patients, and one's family because of insufficient supplies of personal protective equipment; not being able to provide quality care to every severely ill patient; or taking on roles for which one feels inadequately trained.

While the COVID-19 pandemic is unprecedented, it has also amplified problems that were already troubling our healthcare system. For example, a range of factors were contributing to moral injury in nurses long before the pandemic, such as poor team communication, lack of input into clinical decisions, disagreements with physicians about patient care, unsafe staffing, and inappropriate use of resources.

When nurses find themselves in situations where they feel they cannot live up to their own values, or where their teams are not meeting high standards of care, they may experience negative feelings about themselves, such as guilt or shame, as well as feelings of being devalued and voiceless, which can lead to distrust of colleagues or of the leaders of their organization.

Intense feelings of moral injury can contribute to the development of mental health challenges, and the accumulating effect of moral injuries over time can have long-lasting effects on one's sense of self.

Nurse Leaders Should Start the Conversation

Nurse leaders may not be able to address all aspects of moral injury, but there are actions they can take to engage their teams in working on local solutions.

The first step is to introduce or review the concept of moral injury with their teams so that it can become a lens through which individuals think about their own experiences. This conversation could start as part of a huddle but also think about if there are other forums for discussion as well. For example, is there an ethicist affiliated with the organization who could facilitate a discussion?

More informal peer groups can also be a venue for "soul repair" as team members forge connections with each other by sharing stories and reflections on situations where they experienced moral injury.

It's important to also frame the issue in a positive light. While a focus on moral injury sheds light on the nature and contours of the problem, the goal is to move from an analysis of the current state to a vision of the desired future state. Thus, the conversation should also be about what joy could look like in the work environment.

If moral injury is characterized by a sense of disconnection from one's calling, then joy is, in part, a deep sense of connection to a calling; it's when, at the end of the day, you feel a sense of fulfillment in being a nurse. What will it take to get there?

Once the team is thinking and talking about moral injury, everyone can work together to take action. If moral injury happens when a clinician feels that patients are not receiving high-quality care, then a question to pose to the team is, "What gets in the way of you or your team providing high-quality care?" Answers to this question that have to do with poorly designed workflows, problems with team communication, inefficient use of time or resources, etc., are candidates for the design, testing, and implementation of a change in practice.

Learn more about moral injury.